By Topic: Provider Enrollment & Certification

The IRS Form CP 575 is an Internal Revenue Service generated letter you receive from the IRS granting your Employer Iden... (more)

The IRS Form CP 575 is an Internal Revenue Service generated letter you receive from the IRS granting your Employer Identification Number (EIN) linking it with your legal business name (LBN). A copy of your CP 575 may be required by the Medicare contractor to verify the provider or supplier’s EIN and LBN. Any other IRS document showing the provider or supplier's EIN and LBN is also acceptable for enrollment purposes. (FAQ2009)
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Yes. If you submitted an enrollment application for ordering/referring purposes on paper or via Internet-based PECOS and... (more)

Yes. If you submitted an enrollment application for ordering/referring purposes on paper or via Internet-based PECOS and would like to check the status, you may do so by going to CMS Medicare provider/supplier enrollment website and view the “Pending” Ordering Referring Report. This report contains the NPIs and the names of providers who have current enrollment records in process in PECOS and are of a type/specialty that is eligible to order and refer. This report is updated weekly. Please remember that these applications have not been fully processed and are awaiting contractor review. (FAQ8199)
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Providers and suppliers should report changes using the applicable paper provider enrollment application (CMS-855) for your provider/supplier type or submit an electronic application using Internet-Based PECOS. More information is available at: "http://www.cms.gov/MedicareProviderSupEnroll".

If both the physician and the group are already enrolled with the same carrier, the physician and the group together are... (more)

If both the physician and the group are already enrolled with the same carrier, the physician and the group together are required to complete a CMS 855R showing the date the physician joined the group and reassigned benefits to the group. If a physician leaves a group, the physician or the group should complete the CMS 855R, showing the date the physician left the group. When leaving the group, the CMS 855R does not need to be signed by both the physician and the group.
If either the physician or the group have not enrolled with the carrier, they must first complete the appropriate CMS 855 for either an individual (CMS 855I) or group (CMS 855B) before the reassignment can be effective. (FAQ1983)
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Section 6401(a) of the Affordable Care Act (ACA) requires the Secretary to impose a fee on each "institutional provid... (more)

Section 6401(a) of the Affordable Care Act (ACA) requires the Secretary to impose a fee on each "institutional provider of medical or other items or services and suppliers." This includes groups and suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). The fee is to be used by the Secretary to cover the cost of program integrity efforts including the cost of screening associated with provider enrollment processes, including those under section 1866(j) and section 1128J of the Social Security Act. The application fee is currently $542 for CY2014; however, based upon provisions of the ACA this fee will vary from year-to-year based on adjustments made pursuant to the Consumer Price Index for Urban Areas (CPI-U). The application fee is to be imposed on institutional providers, groups and DMEPOS suppliers that are newly-enrolling, re-enrolling/re-validating, or adding a new practice location. CMS has defined "institutional provider" to mean any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A, CMS-855B (except physician and non-physician practitioner organizations), or CMS-855S or the associated Internet-based PECOS enrollment application.

All providers/suppliers are required to submit a new Form CMS-588 with their initial enrollment and their revalidat... (more)

All providers/suppliers are required to submit a new Form CMS-588 with their initial enrollment and their revalidation application. Excluded from this requirement are individual providers reassigning all benefits to a group. Providers/suppliers must include with their Form CMS-588 confirmation of account information on bank letterhead or a voided check. Documentation must contain the name on the account, electronic routing transit number, account number and account type (i.e., checking or savings). The account name to which EFT payments are made must be the legal name of the business as reported to the Internal Revenue Service (IRS). (FAQ3709)
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The application fee is currently $553 for CY2015; however, based upon requirements set forth in Section 6401(a) of the A... (more)

The application fee is currently $553 for CY2015; however, based upon requirements set forth in Section 6401(a) of the ACA, this fee will vary from year-to-year based on adjustments made pursuant to the Consumer Price Index for Urban Areas (CPI-U). (FAQ3133)
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If the application is submitted complete and with all required supporting documentation, it should be processed in less ... (more)

If the application is submitted complete and with all required supporting documentation, it should be processed in less than 60 days. If development is required, it may take up to 90 days. If you are a provider type that requires a site visit, additional time may be required. (FAQ9166)
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In accordance with the Patient Protection and Affordable Care Act, Section 6401, all new and existing providers must be ... (more)

In accordance with the Patient Protection and Affordable Care Act, Section 6401, all new and existing providers must be reevaluated under the new screening guidelines in Section 6028. Medicare requires all enrolled providers & suppliers to revalidate enrollment information every five years while certain suppliers, including physicians who furnish durable medical equipment (DME), are required to revalidate their information every three years (reference 42 CFR 424.57(e)). To ensure compliance with these requirements, existing regulations at 42 CFR 424.515(d) provide that CMS is permitted to conduct off-cycle revalidations for certain program integrity purposes. For more details refer to: "http://www.cms.gov/MLNMattersArticles/downloads/MM7350.pdf"

Providers and suppliers, including physicians, are required to revalidate their information every five years on the anni... (more)

Providers and suppliers, including physicians, are required to revalidate their information every five years on the anniversary of their approved PECOS enrollment date, while certain suppliers, including physicians who furnish durable medical equipment (DME), are required to revalidate their information every three years. Medicare Contractors will notify providers/suppliers at least 60-days prior to their revalidation date. (FAQ3687)
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In Section 4B of the CMS-855I, the NPI of the Group should be entered if it has been issued to the Group. If you are jo... (more)

In Section 4B of the CMS-855I, the NPI of the Group should be entered if it has been issued to the Group. If you are joining a group, the group is responsible for providing you with their current Provider Identification Number (PIN) and the NPI, if they have been issued. (FAQ2011)
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Each unique Tax Identification Number (TIN) requires a separate CMS 855 form. If multiple practice locations contain the same TIN, submit one 855 application and include separate Section 4C pages to identify each practice location. (FAQ9192)
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Providers/suppliers should continue to submit routine changes in a timely manner. If the provider/supplier also receives... (more)

Providers/suppliers should continue to submit routine changes in a timely manner. If the provider/supplier also receives a request for revalidation from their Medicare Contractor, they should separately respond to that request. (FAQ3765)
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Yes, using Internet-based PECOS to revalidate allows you to review information currently on file, update and submit your... (more)

Yes, using Internet-based PECOS to revalidate allows you to review information currently on file, update and submit your revalidation via the Internet. If the provider/supplier uses Internet-based PECOS, they are not required to complete the entire application and only need to update those sections that have changed. However, if you revalidate on a paper CMS 855 application, you must complete the entire application again. (FAQ3717)
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Internet-based PECOS now allows providers to sign all Medicare enrollment applications electronically. Any Individual Provider application (855-I) containing new reassignments (855-R) can be electronically signed as part of the submission process; however, you must select the Authorized Official / Delegated Official (AO/DO) for the Organization that is accepting the reassignment and enter that official’s email address. The official then will be required to follow the instruction in the email and electronically sign the application. If an individual provider or AO/DO does not want to make use of the e-signature process, they can simply follow the current process of printing and signing the certification statement (which then needs to be mailed to the appropriate contractor).

Application fees must be made electronically through Pay.gov. However, providers and suppliers who take advantage ... (more)

Application fees must be made electronically through Pay.gov. However, providers and suppliers who take advantage of the internet-based PECOS application process will no longer have to separately access Pay.gov to make payments. As you complete your electronic application in PECOS, you will be automatically directed to Pay.gov to make your payment. When that transaction is complete you will be returned to internet-based PECOS to complete your application. Your payment information will be automatically associated with your electronic enrollment application. You will have the option to make your payment after you submit your enrollment application if you choose to do so. For information on paying the fee outside of internet-based PECOS, follow the instructions for thos providers and suppliers who continue to use the CMS 855 paper applications. For providers and suppliers who continue to use the 855 paper enrollment application, you will access Pay.gov using the following URL: "https://pecos.cms.hhs.gov/pecos/feePaymentWelcome.do" Complete the Medicare Application Fee form and click the 'PAY NOW' button. You will be redirected to enter and submit payment collection information. At the conclusion of collection process you will receive a receipt indicating the status of your payment. Please print a copy for your records. We strongly recommend that you attach this receipt to the completed CMS-855 paper application submitted to your Medicare contractors. (FAQ3135)
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If you wish to enroll to be reimbursed for the covered services furnished to Medicare beneficiaries, you must complete t... (more)

If you wish to enroll to be reimbursed for the covered services furnished to Medicare beneficiaries, you must complete the CMS-855I application. The CMS-855O should only be completed if you are seeking to enroll solely to order and certify and/or prescribe Part D drugs.

If an NPI were obtained and the applicant found that he/she/it should not have obtained one, the NPI holder should send ... (more)

If an NPI were obtained and the applicant found that he/she/it should not have obtained one, the NPI holder should send a request to the NPI Enumerator to have the NPI deactivated. The NPI holder can do this at any time by completing the NPI Application/Update Form (CMS-10114) for deactivation (see Section 1A3 and application instructions for details regarding the completion of the application for deactivation purposes). The application form can be downloaded at "http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS10114.pdf", or a copy can be requested from the NPI Enumerator by contacting them at 1-800-465-3203. (FAQ8242)
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Veterinarians are not eligible for NPIs because they do not meet the regulatory definition of “health care provider” as ... (more)

Veterinarians are not eligible for NPIs because they do not meet the regulatory definition of “health care provider” as defined at 45 CFR 160.103. However, if a veterinarian fulfills the definition of “health care provider” in a profession other than furnishing veterinary services (for example, if a veterinarian is also a nurse practitioner and, as a nurse practitioner, meets the definition of “health care provider”), the veterinarian would be eligible for an NPI but would select a Nurse Practitioner code (not a Veterinarian code) from the Healthcare Provider Taxonomy Code Set when applying for an NPI. Please be advised that just because the Healthcare Provider Taxonomy Code Set has a code for “Veterinarian” does not mean a veterinarian is a “health care provider” and, thus, eligible for an NPI. Any entity that insists veterinarians obtain an NPI are attempting to require veterinarians to obtain NPIs fraudulently (i.e., because the NPI Application/Update Form and its Internet equivalent require that the NPI applicant indicate that he/she/it meets the regulatory definition of “health care provider” and a veterinarian does not). (FAQ8240)
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In order to be considered for reactivation you need to submit a revalidation application by using the Internet-based PEC... (more)

In order to be considered for reactivation you need to submit a revalidation application by using the Internet-based PECOS application or submitting a paper CMS-855 form. Once that application is received by your Medicare Contractor, the deactivation will be removed and your revalidation application processed. The Medicare Contractor will mail you an approval letter informing you of a successful reactivation, if applicable. If your revalidation is received within a certain period of time, you will maintain your original Provider Transaction Access Number (PTAN) and effective date. (FAQ9184)
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There are three basic requirements for ordering/referring. First, the physician or non-physician practitioner m... (more)

There are three basic requirements for ordering/referring. First, the physician or non-physician practitioner must be enrolled in Medicare in an approved or an opt-out status. Second, the ordering/referring National Provider Identifier (NPI) on the claim must be for an individual physician or non-physician practitioner (not an organizational NPI). Third, the physician or non-physician practitioner must be of a specialty type that is eligible to order and refer.

All changes in ownership and authorized/delegated officials must be reported when submitting your revalidation applicati... (more)

All changes in ownership and authorized/delegated officials must be reported when submitting your revalidation application in section 5/6. The certification statement should be signed by the new authorized or delegated official. (FAQ3705)
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Section 1866 (j)(2) of the Act requires the Secretary to determine the level of provider enrollment screening applicable... (more)

Section 1866 (j)(2) of the Act requires the Secretary to determine the level of provider enrollment screening applicable to providers and suppliers according to the risk of fraud, waste and abuse to the program posed by particular provider and supplier categories. Medicare contractors will screen all revalidation applications based on CMS assessment of risk and assignment to a screening level of 'limited', "moderate," or "high." A complete description of the screening levels and procedures applicable to each category of provider specialty can be found in Section 15.19.2 of the Medicare Program Integrity Manual at "http://www.cms.gov/manuals/downloads/pim83c15.pdf" (FAQ3685)
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The final rule states that State-licensed residents may enroll to order and/or certify and may be listed on claims.&nbsp... (more)

The final rule states that State-licensed residents may enroll to order and/or certify and may be listed on claims. Claims for covered items and services from un-licensed interns and residents must specify the name and NPI of the teaching physician. However, if States provide provisional licenses or otherwise permit residents to practice or order and certify services, CMS is allowing them to enroll to order and certify, consistent with State law. (FAQ8183)
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The purpose of this revalidation is to ensure all provider enrollment records are accurate and up to date. Generally, CM... (more)

The purpose of this revalidation is to ensure all provider enrollment records are accurate and up to date. Generally, CMS does not contemplate taking administrative action against a provider/supplier for updating their records even though it may not have been done timely. However, CMS does reserve the right to take administrative action against those in certain situations where the failure to report the change would have caused the provider/supplier to be to ineligible for enrollment in the Medicare program, such as a change of ownership or a change in tax identification number. (FAQ3701)
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Medicare requires that providers and suppliers inform Medicare of changes in any enrollment information. In accordance w... (more)

Medicare requires that providers and suppliers inform Medicare of changes in any enrollment information. In accordance with 42 CFR section 424.516, providers and suppliers must report a change in enrollment information within 90 days of said change. CMS does not contemplate taking administrative action against a provider/supplier for not updating their records in a timely manner. However, CMS does reserve the right to take administrative action against providers/suppliers in certain situations where the failure to report the change would have caused them to be ineligible for enrollment in the Medicare program. (FAQ9674)
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Yes, your Medicare Contractor will send an approval letter when your revalidation application has been processed. To che... (more)

Yes, your Medicare Contractor will send an approval letter when your revalidation application has been processed. To check the status of your Medicare enrollment you can use the PECOS Self Service Application available at https://pecos.cms.hhs.gov/pecos/sscHome.do. You can also access the PECOS Self Service Application via the link on the Internet-based PECOS website https://pecos.cms.hhs.gov/pecos/login.do. Please note, the 60-day requirement for revalidating your Medicare enrollment is satisfied once you submit your application. (FAQ9188)
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Internet-based PECOS allows you to review information currently on file, update and submit your revalidation via the Int... (more)

Internet-based PECOS allows you to review information currently on file, update and submit your revalidation via the Internet. Internet-based PECOS is a tailored application process which means you only supply information relevant to your application. Revalidating using the paper application requires completion of the entire paper application. In addition, completing the revalidation application on line is faster than the paper based enrollment (45 day processing time in most cases, vs. 60 days for paper). (FAQ9170)
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The Medicare Contractor should remove the deactivation upon receipt of your revalidation application. If this does not o... (more)

The Medicare Contractor should remove the deactivation upon receipt of your revalidation application. If this does not occur please contact your Medicare Contractor. Medicare Contractor contact information for each State can be found at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/contact_list.pdf on the CMS website. (FAQ9186)
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In order to be eligible for an NPI, the applicant must meet the definition of a “health care provider” as defined in the... (more)

In order to be eligible for an NPI, the applicant must meet the definition of a “health care provider” as defined in the HIPAA regulations (45 CFR 160.103). If the applicant does not meet the definition of a “health care provider,” then the applicant is not eligible for the NPI (regardless of whether or not an applicable Healthcare Provider Taxonomy code exists). Please keep in mind that the Healthcare Provider Taxonomy Code Set was developed prior to the passage of the HIPAA legislation and, therefore, was not created for the express purpose of unique identification of health care providers for assignment of NPIs. The Healthcare Provider Taxonomy Code Set was the most comprehensive list of health care providers (and other providers) in existence at the time the NPI regulation was written (and still is today). Ensuring the uniqueness of a health care provider is essential in the assignment of NPIs, and capturing provider “type” (i.e., Healthcare Provider Taxonomy Code) via the NPI Application/Update Form and its Internet equivalent is one way to help uniquely identify a health care provider. Therefore, by regulation, we require that NPI applicants select codes from that code set which best describe their provider “type” when applying for NPIs. (FAQ8244)
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Failure to respond to a revalidation notice could result in the deactivation of your Medicare billing privileges. ... (more)

Failure to respond to a revalidation notice could result in the deactivation of your Medicare billing privileges. Deactivation means you will no longer be reimbursed for Medicare services. (FAQ3699)
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Yes, you will receive a letter requesting the missing information via mail, fax or email. All information is due back to... (more)

Yes, you will receive a letter requesting the missing information via mail, fax or email. All information is due back to your Medicare Contractor within 30 days or you risk deactivation of your Medicare billing privileges. Medicare Contractors frequently have to develop for missing Legal Business Names (LBNs), Internal Revenue Services (IRS) CP-575 documentation verifying LBNs and Employer Identification Numbers (EINs) and practice location information in Section 4 of the CMS-855 paper application. Please refer to the Revalidation Checklist to ensure you have addressed all required items prior to submitting to your Medicare Contractor. Failure to submit this documentation could result in a delay in processing your application. (FAQ9190)
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You need to ensure that the providers from whom you accept orders and referrals have current Medicare enrollment records... (more)

You need to ensure that the providers from whom you accept orders and referrals have current Medicare enrollment records or are in an opt-out status and are of a type/specialty that is eligible to order or refer in the Medicare program. If you are not sure that the provider who is ordering or referring items or services meets those criteria, it is recommended that you check the Ordering Referring Report. Ensure you are correctly spelling the Ordering/Referring Provider’s name. The Ordering Referring Report will be replaced twice a week to ensure it is current. It is possible that you may receive an order or a referral from a physician or non-physician practitioner who is not listed in the Ordering Referring Report but who may be listed on the next Report. Make sure your claims are properly completed. On paper claims (CMS-1500), in item 17, only include the first and last name as it appears on the Ordering and Referring file found on CMS.gov. Do not use “nicknames”, credentials (e.g., “Dr.”, “MD”, “RPNA”, etc.) or middle names (initials) in the Ordering/Referring name field, as their use could cause the claim to fail the edits. Ensure that the name and the NPI you enter for the Ordering/Referring Provider belong to a physician or non-physician practitioner and not to an organization, such as a group practice that employs the physician or non-physician practitioner who generated the order or referral. If there are additional questions about past informational messages or current denial edits, billing providers should contact their local carrier, A/B MAC, or DME MAC. Billing Providers should be aware that claims that are denied because they failed the ordering/referring edit shall not expose a Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice is not appropriate in this situation. This is consistent with the preamble to the final rule which implements the Affordable Care Act requirement that physicians and eligible professionals enroll in Medicare to order and certify certain Medicare covered items and services including home health, DMEPOS, imaging and clinical laboratory.

This letter includes all of the provider’s active PTANs as listed in PECOS. It is the provider’s responsibility to reval... (more)

This letter includes all of the provider’s active PTANs as listed in PECOS. It is the provider’s responsibility to revalidate all of their information; therefore, if the request is for an individual provider, the PTANs may be for reassignments to another group. Please ensure that the individual provider is involved in their revalidation process so that they can confirm if the PTAN is still needed. If in fact the PTAN is not needed, it needs to be deactivated. This information should be submitted on the application when the revalidation is submitted. (FAQ9178)
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A list of providers and suppliers who have been sent revalidation requests are available at: "... (more)

A list of providers and suppliers who have been sent revalidation requests are available at: "http://www.cms.gov/MedicareProviderSupEnroll/". The lists are generated on a bimonthly basis. Providers and suppliers using Internet-based PECOS will also be able to see if a request for revalidation has been sent by the Medicare Contractor, as a “Revalidation Notice Sent” date will be displayed on the My Enrollments page. This will reflect the date the Revalidation Letter was mailed by the Medicare Contractor to the provider/supplier. The date will display on the My Enrollments page for 120 days. (FAQ10804)
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Various sections of the Social Security Act and the Code of Federal Regulations require providers and suppliers to furni... (more)

Various sections of the Social Security Act and the Code of Federal Regulations require providers and suppliers to furnish information concerning the amounts due and the identification of individuals or entities who furnish medical services to beneficiaries before payment can be made. This helps protect the Medicare trust funds, the beneficiaries, and the vast majority of honest providers and suppliers from the few scrupulous providers and supplier intent on defrauding the program. Keeping your enrollment information up to date also helps prevent identity theft and use of your information without your knowledge. CMS is required under Section 6401(a) of the Affordable Care Act (ACA) to apply increased enrollment screening criteria to all said suppliers. In order to meet these requirements, Medicare requires providers and suppliers to revalidate their Medicare enrollment information periodically. Providers and suppliers, including physicians, are required to revalidate their information every five years, while certain suppliers, including physicians who furnish durable medical equipment (DME), are required to revalidate their information every three years. CMS is currently undertaking an "off-cycle" revalidation process now for most providers, meaning a provider or supplier may be asked to revalidate their enrollment sooner than three or five years. (FAQ3683)
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Physicians and non-physician Practitioners who have opted-out of the Medicare program are not required to revalidate.&nb... (more)

Physicians and non-physician Practitioners who have opted-out of the Medicare program are not required to revalidate. However, if a physician or practitioner wants to continue his/her opt out status without interruption (i.e., after the physician’s or practitioner's original 2-year opt out period expires), then the physician or practitioner must file another opt out affidavit with the Medicare Part B contractor that is responsible for his/her State and must enter into new private contracts with all Medicare beneficiaries to whom they furnish services that would otherwise be covered by Medicare, except those who are in need of emergency or urgently needed care. Opt-out physicians cannot sign such contracts with beneficiaries in need of emergency or urgent care services. (FAQ3759)
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Yes, prescribers of Part D drugs must enroll in Medicare or have a valid record of opting- out. This includes dent... (more)

Yes, prescribers of Part D drugs must enroll in Medicare or have a valid record of opting- out. This includes dentists. However, there are circumstances, based on varying allowances of state laws that allow some pharmacists to prescribe. Pharmacists who fall into this small category should stay tuned for more detailed guidance. However, prescribers who are not enrolled and who have not opted- out may start enrolling in Medicare or submitting an opt- out affidavit by submitting the proper information through their respective Medicare Administrative Contractors (MACs). Prescribers can either visit their MACs website or access information on our enrollment website by going to CMS.gov and clicking on “Medicare Provider-Supplier Enrollment” under the “Provider Enrollment & Certification” heading. This requirement applies to those who bill Medicare as well as those who do not. Providers who wish to enroll solely to prescribe Part D drugs and who do not bill Medicare for services provided to Medicare beneficiaries can complete an abbreviated enrollment form and process that the MACs can explain.

Providers/suppliers are still required to provide confirmation of account information via bank letterhead or voided check. Providers/suppliers can submit an (1) original, (2) photocopy, (3) fax, or (4) scanned secure e-mail copy of the voided check or letter from the bank. (FAQ7465)
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In accordance with the Affordable Care Act (ACA) and implementing regulations, the Centers for Medicare and Medicaid Services (CMS) must conduct a fingerprint based background check on all individuals with a 5 percent or greater ownership interest in a provider or supplier that falls under the high risk category for purposes of enrollment screening. Please see 42 CFR §424.518(c)(2)(B).

There will be no gap in payment once your complete revalidation application is received by the Medicare contractors. ... (more)

There will be no gap in payment once your complete revalidation application is received by the Medicare contractors. You must respond to the request to revalidate your provider enrollment within 60-days from the date of receipt of the application. Failure to respond to the request may result in deactivation of your provider identification number and enrollment billing privileges. We strongly urge all providers and suppliers to carefully review their applications to make sure they are accurately completed, including appropriate signatures, and required documents, before submitting them to the Medicare Administrative Contractors (MACs).

Excluded from the revalidation requirement are providers/suppliers that were initially enrolled or voluntarily revalidat... (more)

Excluded from the revalidation requirement are providers/suppliers that were initially enrolled or voluntarily revalidated on or after March 25, 2011, based up receipt date, and were subject to the screening provisions of the Affordable Care Act, Section 6028. Also excluded from revalidation are providers enrolled solely to order and refer items or services to Medicare beneficiaries and practitioners who have opted out of the Medicare program. However, you will be required to revalidate your enrollment information either 3 or 5 years (based on your provider/supplier type) after your initial enrollment date. Please contact your Medicare Contractor if you believe you meet these requirements and received a revalidation letter. (FAQ3715)
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Announced and unannounced site visits are required prior to enrollment for initial enrollment, new practice locations... (more)

Announced and unannounced site visits are required prior to enrollment for initial enrollment, new practice locations and for revalidation of providers and suppliers in the moderate and high categorical screening levels. CMS has contracted with a National Site Visit Contractor (NSVC) to conduct site visits for all providers and suppliers except for the Durable Medical Equipment (DMEPOS) which will continue to be conducted by the National Supplier Clearinghouse. MSM Security Services, LLC was awarded the national site visit contract. MSM and its subcontractors, Computer Evidence Specialists, LLC (CES) and Health Integrity, LLC (HI) are authorized by CMS to conduct the provider and supplier site visits. Inspectors performing the site visits shall possess a photo ID and a letter of authorization issued and signed by CMS that the provider or supplier may review.

Once you receive the request for revalidation from your Medicare Contractor, the quickest and easiest way to complete yo... (more)

Once you receive the request for revalidation from your Medicare Contractor, the quickest and easiest way to complete your application is using Internet-based PECOS located at "https://pecos.cms.hhs.gov/pecos/login.do". Paper 855 enrollment applications are also available at "http://www.cms.gov/CMSFORMS/CMSForms/list.asp". You have 60 days from the post mark date of the revalidation notification letter to submit your completed paper or Internet-based PECOS electronic revalidation application.

CMS published the [CMS-6010-F] RIN 0938-AQ01 Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements on April 24, 2012. The rule implements provisions of the Affordable Care Act to ensure the Medicare program is paying appropriately for services. The rule helps reduce the Medicare program vulnerability by giving CMS the ability to tie specific Medicare claims to the ordering or referring physician or eligible professional as well as implements system requirements to assure that individuals ordering or referring care for beneficiaries are actually meeting Medicare enrollment requirements. The final rule requires medical documentation retention and provision standards for providers and suppliers that order, certify, and provide items and services for Medicare beneficiaries. The rule can be viewed at "https://www.federalregister.gov/regulations/0938-AQ01/changes-in-provider-and-supplier-enrollment-ordering-and-referring-and-documentation-requirements-an".

Once you have logged into PECOS, select “My Enrollments” from the Welcome Page and then “View Enrollments”. Identify the... (more)

Once you have logged into PECOS, select “My Enrollments” from the Welcome Page and then “View Enrollments”. Identify the enrollment you would like to revalidate and select the “Revalidate” button. Please review all contents and make any necessary changes. Note: Medicare Contractors will notify providers/suppliers at least 60-days prior to their revalidation date. (FAQ9172)
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If you cannot remember your User ID, you may select the “Forgot User ID?” link on the PECOS home page. Forgotten passwor... (more)

If you cannot remember your User ID, you may select the “Forgot User ID?” link on the PECOS home page. Forgotten passwords can be retrieved by selecting the “Forgot Password” link also from the home page. Users will be directed to the Identify Access Management System (I&A) and should follow the instructions on the screen for retrieving their forgotten information. (FAQ9176)
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CMS published the CMS-4159-F final rule titled Policy and Technical Changes to the Medicare Advantage and the Medicare P... (more)

CMS published the CMS-4159-F final rule titled Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Program for Contractor Year 2015 on May 19, 2014. This regulation was authorized by section 6405(c) of the Affordable Care Act. The final rule gives CMS the authority to:• Require physicians and eligible professionals who write prescriptions for Part D drugs to be enrolled in Medicare or have a valid record of opting- out of Medicare for their prescriptions to be covered under Part D. • Revoke a physician or eligible professional’s Medicare enrollment if: o An abusive pattern or practice of prescribing Part D drugs is discoveredo His/her Drug Enforcement Administration (DEA) Certificate of Registration is suspended or revoked

Yes. With the implementation of Section 6405 of the Affordable Care Act, CMS permits certain physicians or other elig... (more)

Yes. With the implementation of Section 6405 of the Affordable Care Act, CMS permits certain physicians or other eligible professionals to enroll in the Medicare program for the sole purpose of ordering or referring items or services for Medicare beneficiaries. These physicians or other eligible professionals do not and will not send claims to a Medicare contractor for the services they furnish. The physicians or other eligible professionals who may wish to enroll in Medicare solely for the purpose of ordering and referring include, but are not limited to, those who are: Employed by the Department of Veterans Affairs (DVA); Employed by Federally Qualified Health Affairs Centers (FQHCs) or Rural Health Clinics (RHCs); Employed by the Public Health Service (PHS) or Critical Access Hospitals (CAHs); Employed by the Department of Defense (DOD) or TRICARE; Licensed residents and physicians in a fellowship; Dentists, including oral surgeons; Employed by Indian Health Services (IHS) or tribal organizations; and Pediatricians.

Any new enrollment applications that have not been approved at the time the moratoria are implemented will be denied. The provider or supplier will not be allowed to enroll in the affected counties regardless of the time an application has been pending. An applicant that has received a letter from their Medicare Administrative Contractor (MAC) notifying the applicant of approval and acceptance into the program is considered approved, and thus would not be subject to the moratoria. For applications denied due to the moratoria, any application fee paid to CMS will be refunded.(FAQ10424)
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Questions regarding Medicare application fee payment policies may be sent to your local Medicare Administrative Contractor. All Medicare Contractor's contact information is found on our website. Please visit "https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll" and click on the "Contact Information for Medicare Enrollment Contractors" in the Downloads box. This will bring up a list, in alphabetical order by state, of all contractors’ mailing addresses and contact telephone numbers.

Your Medicare Contractor will be sending out revalidation letters over an extended period of time. Please DO NOT subm... (more)

Your Medicare Contractor will be sending out revalidation letters over an extended period of time. Please DO NOT submit a revalidation application until you have been asked to do so by your Medicare Contractor.

No. If the revalidation letter is for the group, then the revalidation is for the entity only. If the individuals associ... (more)

No. If the revalidation letter is for the group, then the revalidation is for the entity only. If the individuals associated with the group have not previously revalidated, their letters will be mailed at a separate time. (FAQ9180)
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Medicare payment cannot be made directly or indirectly for services furnished by an opt- out physician, except for certain emergency and urgent care services. Therefore, no payment may be made under Medicare or under a Medicare Advantage Plan for the services furnished by an opt- out physician. (The drug is still Part D coverable.)

If you are submitting more than one payment, CMS uses the Tax ID to match the payment to your application. It does not m... (more)

If you are submitting more than one payment, CMS uses the Tax ID to match the payment to your application. It does not matter which payment gets applied to the PTAN. Each PTAN is a separate enrollment. Each PTAN is subject to a separate fee. Note: The application fee does not apply to physicians, non-physician practitioners, physician group practices, and non-physician group practices unless they are also Durable Medical Equipment Suppliers (DME). For more information please visit: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareApplicationFee.html. (FAQ9670)
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CMS published a Federal Register document announcing the extension of its temporary moratoria on the Medicare, Medicaid ... (more)

CMS published a Federal Register document announcing the extension of its temporary moratoria on the Medicare, Medicaid or the Children’s Health Insurance Program (CHIP) for the enrollment of new ambulance suppliers, home health agencies and home health agency sub-units in six geographic areas. In July 2013, January 2014 and July, 2014, CMS used this new authority provided by the Affordable Care Act. On January 29, 2015, CMS announced the extension of the first two waves of the agency’s use of moratoria to fight fraud and safeguard taxpayer dollars while ensuring patient access to care is not interrupted. (FAQ10406)
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You will receive a separate request to revalidate from each of the Medicare Administrative Contractors (MACs) and you... (more)

You will receive a separate request to revalidate from each of the Medicare Administrative Contractors (MACs) and you will need to respond to each MAC separately. Once you receive the request for revalidation from your MAC, the quickest and easiest way to complete your application is through Internet-based PECOS ("https://pecos.cms.hhs.gov/pecos/login.do"). Paper 855 enrollment applications are also available at "http://www.cms.gov/CMSFORMS/CMSForms/list.asp". You will have 60 days from the date of the letter to submit a revalidation application. Failure to submit a complete enrollment application(s) and all supporting documentation within 60 calendar days of the postmark of the revalidation letter you received from your Medicare Contractor may result in your Medicare billing privileges being deactivated. If additional time is needed, you may request one 60-day extension, which will begin on the date of the request, if the extension is approved.

The CMS Fingerprint Based Background Check Contractor (FBBC) will provide at least three locations most convenient to you, with at least one location being a local, state or federal law enforcement agency. (FAQ9884)
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Only Medicare-enrolled approved or opted-out individual physicians and non-physician practitioners of a certain speci... (more)

Only Medicare-enrolled approved or opted-out individual physicians and non-physician practitioners of a certain specialty type may order/refer for Part B (clinical lab and imaging services) and DMEPOS Medicare beneficiary services. These individuals include: Physicians (Doctor of Medicine or Osteopathy, Doctor of Dental Medicine, Doctor of Dental Surgery, Doctor of Podiatric Medicine, Doctor of Optometry); Physician Assistants; Clinical Nurse Specialists; Nurse Practitioners; Clinical Psychologists; Certified Nurse Midwives; Clinical Social Workers; and Interns, residents, and fellows. The following exception is applicable for Part B services: Optometrists may only order and refer laboratory and X-Ray services payable under Medicare Part B and DMEPOS products/services. Organizational providers cannot order and refer.

If you are asked to revalidate, please respond to the revalidatation request. Only if you have already retired and are n... (more)

If you are asked to revalidate, please respond to the revalidatation request. Only if you have already retired and are no longer serving Medicare beneficiaries in any capacity, you should notify your Medicare contractor in writing so that your provider enrollment records can be updated to correctly reflect your retirement. On your letterhead submit a signed, dated, written notice to the Medicare Administrative Contractor (MAC) to notify them of your retirement. This will help ensure that your Medicare enrollment record is updated correctly and in accordance with the information you have personally provided. This will also help eliminate the potentially fraudulent use of your provider identification and enrollment information. (FAQ3689)
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Yes, a newly enrolling or revalidating FQHC is subject to the application fee. However, if your entity believes the appl... (more)

Yes, a newly enrolling or revalidating FQHC is subject to the application fee. However, if your entity believes the application fee represents a significant financial hardship, it can request an exception through a hardship waiver request. Such requests are not granted automatically for any particular provider or supplier type; instead, such hardship exception requests are considered on a case-by-case basis. To request a hardship exception, you must submit documentation supporting the request at the time the enrollment application is submitted; otherwise, the application will be returned to you. While we do not prescribe particular documentation that must be submitted, the following would be helpful in helping us determine whether an entity should be granted a hardship exception from the application fee: (a) information on the income distribution of patients; (b) payor mix; (c) evidence that the facility is located in a medically underserved area and/or serves a medically underserved population; (d) amount of bad debt expenses; and (e) amount of charity care/financial assistance furnished to patients. Note that the request for a hardship waiver must be reviewed, and either approved or denied, before the review of the enrollment application will begin; this initial review can take up to 60 days. In addition, if the waiver request is denied, the provider must pay the application fee within 30 calendar days from the date of the waiver denial letter. Failure to do so will result in the denial of the provider's application or, in the case of a revalidation, the revocation of the provider's Medicare billing privileges. (FAQ3465)
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The moratorium does not apply to changes in enrollment status for those providers and suppliers currently enrolled in th... (more)

The moratorium does not apply to changes in enrollment status for those providers and suppliers currently enrolled in these programs, including practice location; changes in provider or supplier information such as phone number or addresses; or changes in ownership (except changes in ownership of home health agencies that would require an initial enrollment under 42 CFR 424.550). HHAs and ambulance suppliers in the affected areas should continue to submit these types of application changes as required under current CMS regulations. (FAQ10410)
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Documentation required at the time of a DMEPOS supplier’s enrollment, revalidation and upon the request of the NSC. Documentation must include copy(s) of all applicable licenses required for the DMEPOS/service. The license must contain legible name and license number of the licensed individual.

A provider or supplier designated as a “high” level of risk must submit the fingerprints of all individuals who maintain a 5 % or greater direct or indirect ownership interest in the provider or supplier.

Even if a provider recently submitted changes to their enrollment application, the provider or supplier must still respo... (more)

Even if a provider recently submitted changes to their enrollment application, the provider or supplier must still respond to the revalidation request. Providers and suppliers will be sent written notification to revalidate. Providers and suppliers should respond to those requests within 60-days of the post mark date. If the provider questions the propriety of the request to revalidate they should contact the Medicare Administrative Contractor (MAC). (FAQ3795)
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The Medicare Administrative Contractors (MACs) will send a letter to the applicable providers/suppliers listing the individuals who are required to be fingerprinted. The letter will be mailed to the correspondence address and the special payments address on file with CMS and will list all 5% or greater owners.

The high level of risk is applied to providers and suppliers who are newly enrolling Durable Medicare Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers or Home Health Agencies (HHA).It also applies to providers and suppliers who have been elevated to the high risk category in accordance with the enrollment screening regulations. Please refer to 42 CFR §424.518(c)(3) and the Program Integrity Manual, Chapter 15, Section 15.19.2.C.(FAQ9868)
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Consistent with the Affordable Care Act and 42 CFR § 424.507, suppliers submitting claims for imaging services must identify the ordering or referring physician or practitioner. Imaging suppliers covered by this requirement include the following: Independent Diagnostic Testing Facilities (IDTFs), Mammography Centers, Portable X-ray suppliers, and Radiation Therapy Centers. The rule applies to the technical component of imaging services, and the professional component are excluded from the edits. However, if billing globally, both components will be impacted by the edits and the entire claim will deny if it doesn’t meet the ordering and referring requirements. It is recommended that providers and suppliers bill the global claims separately to prevent a denial for the professional component. (FAQ8215)
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Prescribers can either visit their MACs website or access information on our enrollment website by going to CMS.gov a... (more)

Prescribers can either visit their MACs website or access information on our enrollment website by going to CMS.gov and clicking on “Medicare Provider-Supplier Enrollment” under the “Provider Enrollment & Certification” heading. CMS will also be communicating through MedLearn, posting FAQs to our website, conducting open door forums, and numerous other channels to provide ongoing and updated information to all impacted by this requirement.

Beneficiaries and enrollees should ensure that any prescriptions written for Part D are from a physician or eligible professional that’s either enrolled in Medicare or has opted- out of Medicare. Beneficiaries/ enrollees are encouraged to check with their prescribers to ensure the prescriber is compliant. Beneficiaries/ enrollees may also check the physician compare website on CMS.gov to see if their prescriber is enrolled in Medicare.

Extension requests should be coordinated with your Medicare Contractor and requested in writing (fax/email permissible) or via phone. The Individual provider, the Authorized or Delegated Official of the organization or the enrollment contact person can request the extension. Group extensions can also be requested rather than individual extensions. Group extensions shall also be coordinated through your MACs. Group extensions can only be requested if the provider reassigns all benefits to the group. The Authorized or Delegated Official of the organization or the enrollment contact person can request the group extension. The group shall provide the Providers’ name, National Provider Identifier (NPI) and justification as to why an extension is needed. The extension can be requested in writing (fax/email permissible) or via phone. Please note: extensions must be approved and are not guaranteed. (FAQ9168)
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CMS had made available an enrollment file that identifies providers who are enrolled in Medicare in an approved or op... (more)

CMS had made available an enrollment file that identifies providers who are enrolled in Medicare in an approved or opt- out status. The first iteration of the enrollment file is now available at https://Data.cms.gov. The file contains production data but is considered a test file since the part D enrollment requirements have not been implemented. An updated enrollment file will be generated every two weeks and continue through the December 1, 2015 enforcement date. The file will display provider eligibility as of and after November 1, 2014 (i.e., currently enrolled, new approvals, or changes from opt-out to enrolled as of November 1, 2014). Any inactive providers or periods of inactivity for existing providers prior to November 1, 2014, will not be displayed on the enrollment file. However, any enrollments that become inactive after November 1, 2014, will be on the file with its respective end dates for that given provider. For opted- out providers, the opt- out flag will display a Y/N (Yes/No) value to indicate the periods the provider was opted- out of Medicare. The file will include the provider’s:

• National Provider Identifier (NPI)• First and Last name• Effective and End Dates• Opt- Out Flag

Only Medicare-enrolled or opted-out individual physicians of a certain specialty type may order/refer for Part A when... (more)

Only Medicare-enrolled or opted-out individual physicians of a certain specialty type may order/refer for Part A when a plan of treatment is needed and submitted from an HHA for beneficiary services. These individuals include: Doctors of Medicine or Osteopathy, and Doctors of Podiatric Medicine.

Yes. The claim will deny because the referring provider who is located outside of the US is ineligible to enroll in Medi... (more)

Yes. The claim will deny because the referring provider who is located outside of the US is ineligible to enroll in Medicare. Billing Providers should be aware that claims that are denied because they failed the ordering/referring edit shall not expose a Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice is not appropriate in this situation. This is consistent with the preamble to the final rule which implements the Affordable Care Act requirement that physicians and eligible professionals enroll in Medicare to order and certify certain Medicare covered items and services including home health, DMEPOS, imaging and clinical laboratory. (FAQ9216)
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In these situations, the licensed individual is not required to be an employee (W-2) of the DMEPOS supplier, unless expressly required by state law. The DMEPOS supplier must be licensed and may enter into a contractual arrangement with an appropriate licensed individual who provides the item or service.

Pay.gov is operated by the U.S. Department of the Treasury and is a web-based application that allows you to make online... (more)

Pay.gov is operated by the U.S. Department of the Treasury and is a web-based application that allows you to make online payments to government agencies by electronic check, credit card or by debit from your checking or savings account. (FAQ3139)
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Physicians or other eligible professionals can apply for enrollment for the sole purpose of ordering and referring items... (more)

Physicians or other eligible professionals can apply for enrollment for the sole purpose of ordering and referring items and/or services to Medicare beneficiaries may do so by filling out the paper CMS-855O or they may use Internet-based PECOS. Ordering and referring providers will not be submitting claims to Medicare for services they furnish to Medicare beneficiaries.

No, that does not mean you do not have to revalidate. Your Medicare Contractor will be sending out revalidation letters ... (more)

No, that does not mean you do not have to revalidate. Your Medicare Contractor will be sending out revalidation letters over an extended period of time. Please DO NOT submit a revalidation application until you have been asked to do so by your Medicare Contractor. (FAQ9672)
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CMS is implementing the Fingerprint based background checks per section 6401 of the ACA to enhance Medicare program integrity.The background check requirement will assist in the detection of bad actors who are attempting to enroll in the Medicare program and to remove those currently enrolled.

The edits will determine if the Ordering/Referring Provider (when required to be identified in Part B, DME, and Part A H... (more)

The edits will determine if the Ordering/Referring Provider (when required to be identified in Part B, DME, and Part A HHA claims) (1) has a current Medicare enrollment record and it contains a valid National Provider Identifier (NPI) (the name and NPI must match), and (2) is of a provider type that is eligible to order or refer for Medicare beneficiaries. (FAQ8189)
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No. Do not mail application fee payments. Payments cannot be accepted by mail or phone. Please note that all fees must b... (more)

No. Do not mail application fee payments. Payments cannot be accepted by mail or phone. Please note that all fees must be paid via Pay.gov through CMS' Provider Enrollment, Chain and Ownership System (PECOS) application and paper checks submitted outside of this process will not be accepted. If you are enrolling via a CMS 855 paper form, payments can be made at the Pay.gov website. We strongly recommend that you attach this receipt to the completed CMS-855 paper application submitted to your Medicare contractors. (FAQ3141)
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Failure to submit fingerprints for all individuals with a 5% or greater ownership interest within 30 days of the date of the letter may result in the denial or revocation of the provider or supplier’s Medicare billing privileges.

Yes. While it is acceptable to photocopy the enrollment application, it is unlawful to alter it in any manner. Moreover,... (more)

Yes. While it is acceptable to photocopy the enrollment application, it is unlawful to alter it in any manner. Moreover, original signatures are required on all applications. In addition, stamped or copied signatures are not acceptable. Therefore, although a photocopy of the application is acceptable, a photocopy of the authorized official and/or delegated representative is not acceptable. (FAQ1907)
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You should use the HelpTools available on the Pay.gov site for questions specific to the payment processing. Other quest... (more)

You should use the HelpTools available on the Pay.gov site for questions specific to the payment processing. Other questions regarding payment policies and procedures may be sent to the Medicare provider and supplier enrollment e-mail account at PEOG_Inquiry@cms.hhs.gov. (FAQ3137)
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CMS is monitoring the trends related to home health provider and ambulance supplier enrollment in Medicare to identify e... (more)

CMS is monitoring the trends related to home health provider and ambulance supplier enrollment in Medicare to identify emerging trends in other provider and supplier types, or migration to other geographic areas. (FAQ10422)
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The provider that prescribed the glasses should be listed on the claim as the ordering or referring physician. If the Op... (more)

The provider that prescribed the glasses should be listed on the claim as the ordering or referring physician. If the Ophthalmologist and the Optometrist are one in the same, that person shall be listed. (FAQ8213)
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Yes, however, the scope of review will be limited to whether the temporary moratorium applies to the provider or supplie... (more)

Yes, however, the scope of review will be limited to whether the temporary moratorium applies to the provider or supplier appealing the denial, (i.e., the provider or supplier in question was of a different specialty type and not subject to the moratoria or the provider or supplier in question was located outside of the area where the moratoria were put in place). Further, a provider or supplier may appeal a denial of billing privileges based on temporary moratorium using the existing appeal procedures at 42 CFR Part 498. The agency’s basis for imposing a moratorium is not subject to judicial review under sections 1869 and 1878 of the Social Security Act. (FAQ10426)
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No. If this is the first contact ever made by the supplier to the beneficiary, then the supplier is prohibited from atte... (more)

No. If this is the first contact ever made by the supplier to the beneficiary, then the supplier is prohibited from attempting to solicit the purchase of additional covered items since the supplier only had permission to contact the beneficiary regarding the particular covered item prescribed by the physician. It is only permissable for a DME supplier to make telephone contact with a beneficiary regarding covered items if the beneficiary gave written permission for the supplier to contact him/her, if the supplier has already provided a covered item to the beneficiary and the supplier is calling the beneficiary about such covered item or if the beneficiary has already received a covered item from the supplier in the last 15 months. (FAQ7551)
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Provider Enrollment MACs will verify the EFT form is complete and request an update if it is not complete. Provide... (more)

Provider Enrollment MACs will verify the EFT form is complete and request an update if it is not complete. Provider Enrollment MACs will not verify the information on the EFT form, only its completeness. (FAQ9520)
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The “From Date” on the claim will be used to determine if the claim is paid. Claims submitted with a “From Date” o... (more)

The “From Date” on the claim will be used to determine if the claim is paid. Claims submitted with a “From Date” on or after the date the edits were turned on will be required to have the ordering/referring provider listed. Home Health Agency (HHA) claims submitted for episodes that begin prior to the date the edits were turned on and run thru the implementation date will not be subject to the edits. (FAQ8223)
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CMS is monitoring access to care issues through coordination with State Medicaid Agencies and beneficiary complaints to ... (more)

CMS is monitoring access to care issues through coordination with State Medicaid Agencies and beneficiary complaints to 1-800-Medicare, the CMS Ombudsman and the CMS Regional Offices and Consortia. CMS will also use data analysis, information from law enforcement and CMS’ Program Integrity Field Offices.

If you have a payment you need to change or cancel, please contact CMS’ External User Services Help Desk at 1-866-484-80... (more)

If you have a payment you need to change or cancel, please contact CMS’ External User Services Help Desk at 1-866-484-8049. Pay.gov Customer Service cannot issue refunds or initiate corrections to an incorrect payment. (FAQ7471)
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Excluded from the revalidation requirement are providers/suppliers that were initially enrolled or voluntarily revalidat... (more)

Excluded from the revalidation requirement are providers/suppliers that were initially enrolled or voluntarily revalidated on or after March 25, 2011, based up receipt date, and were subject to the screening provisions of the Affordable Care Act, Section 6028. Also excluded from revalidation are providers enrolled solely to order and refer items or services to Medicare beneficiaries and practitioners who have opted-out of the Medicare program. Please contact your Medicare Contractor if you believe you meet these requirements and received a revalidation letter. After completion of this revalidation cycle, providers and suppliers will resume their normal revalidation cycle (every 3 years for Durable Medical Equipment, Prosthetics Orthotics and Supplies (DMEPOS) suppliers and every 5 years for all other provider and suppliers. However, CMS reserves the right to perform off-cycle revalidations as deemed necessary. (FAQ9158)
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The following link takes you directly to the MLN article which addresses the ACA related enrollment changes: "... (more)

The following link takes you directly to the MLN article which addresses the ACA related enrollment changes: "https://www.cms.gov/MLNMattersArticles/downloads/MM7350.pdf". As of March 25, 2011, Medicare began placing newly-enrolling and existing providers and suppliers in one of three levels of categorical screening: limited, moderate, or high. The risk levels denote the level of the contractor’s screening of the provider or supplier when it initially enrolls in Medicare, adds a new practice location, or revalidates its enrollment information. Chapter 15, Section 19.2.1 of the Program Integrity Manual (PIM) provides the complete list of these three screening categories, and the provider types assigned to each category, and a description of the screening processes applicable to the three categories (effective on and after March 25, 2011), and procedures to be used for each category.

Yes, global billing is still allowed; however, if you are not accredited and you submit a global claim for an ADI servic... (more)

Yes, global billing is still allowed; however, if you are not accredited and you submit a global claim for an ADI service on or after January 1, 2012 the claim will be denied. Note: if you are submitting a claim for the professional component alone on an ADI service, accreditation is not needed. (FAQ3799)
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Effective January 6, 2014, CMS instructed contractors to turn on Phase 2 denial edits on the following claims to chec... (more)

Effective January 6, 2014, CMS instructed contractors to turn on Phase 2 denial edits on the following claims to check for a valid individual National Provider Identifier (NPI) and to deny the claim when this information is invalid. The following claims will be affected: claims from clinical laboratories for ordered tests; claims from imaging centers for ordered imaging procedures; claims from suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) for ordered DMEPOS; and claims from Part A Home Health Agencies (HHAs). Claims submitted identifying an ordering/referring provider with the required matching NPI is missing will continue to be rejected.

Claims from billing providers and suppliers that are denied because they failed the ordering/referring edit shall not ex... (more)

Claims from billing providers and suppliers that are denied because they failed the ordering/referring edit shall not expose a Medicare beneficiary to liability. Therefore, an Advance Beneficiary Notice is not appropriate in this situation. This is consistent with the preamble to the final rule which implements the Affordable Care Act requirement that physicians and eligible professionals enroll in Medicare to order and certify certain Medicare covered items and services including home health, DMEPOS, imaging and clinical laboratory. (FAQ8235)
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Only part B claims submitted for clinical laboratory and imaging services will be impacted by the edits. Imaging service... (more)

Only part B claims submitted for clinical laboratory and imaging services will be impacted by the edits. Imaging services include those furnished by Independent Diagnostic Testing Facilities (IDTFs), Mammography Centers, Portable X-ray suppliers, and Radiation Therapy Centers that are enrolled in Medicare via the CMS–855B. Any services rendered by these entities will be impacted by the denial edits. (FAQ8209)
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In order for the claim from the billing provider (the provider who furnished the item or service) to be paid by Medicare... (more)

In order for the claim from the billing provider (the provider who furnished the item or service) to be paid by Medicare for furnishing the item or service that you ordered or referred, you—the Ordering/Referring Provider—need to ensure that: you have a current Medicare enrollment record or are in opt-out status and you are of a type/specialty that can order or refer items or services for Medicare beneficiaries. Organizational providers cannot order and refer. (FAQ8201)
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The medical records maintained by the DMEPOS supplier must include the DMEPOS supplier’s name, the licensed individual’s... (more)

The medical records maintained by the DMEPOS supplier must include the DMEPOS supplier’s name, the licensed individual’s name, license number, NPI and Medicare Identification number (if issued) of the individual who provided the licensed DMEPOS/service, the date of the DMEPOS/service and location where the DMEPOS/service was provided, as well as the NPI of the physician or eligible professional who ordered or referred the DMEPOS. (FAQ7575)
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The high level of risk is applied to providers and suppliers who are newly enrolling Durable Medicare Equipment, Prosthe... (more)

The high level of risk is applied to providers and suppliers who are newly enrolling Durable Medicare Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers or Home Health Agencies (HHA). It also applies to providers and suppliers who have been elevated to the high risk category in accordance with the enrollment screening regulations. Please refer to 42 CFR §424.518(c)(3) and the Program Integrity Manual, Chapter 15, Section 15.19.2.C.

The MAC, including the National Supplier Clearinghouse (NSC) will notify each supplier to revalidate. Suppliers and prov... (more)

The MAC, including the National Supplier Clearinghouse (NSC) will notify each supplier to revalidate. Suppliers and providers including pharmacies should not submit a revalidation application until requested to do so by the MAC or the NSC MAC. (FAQ3777)
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Doctors of medicine or osteopathy and doctors of podiatric medicine are the only Medicare-enrolled individual physicians... (more)

Doctors of medicine or osteopathy and doctors of podiatric medicine are the only Medicare-enrolled individual physicians who may order/refer for Part A when a plan of treatment is needed and submitted from an HHA for beneficiary services. If the hospitalist is either of those specialties then they may order/refer. (FAQ8221)
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Yes. The moratorium is just one of the many tools that CMS can use as part of its comprehensive program integrity strategy. We are using the temporary enrollment moratoria in coordination with other on-going activities, such as the revalidation project and the Fraud Prevention System, to put additional safeguards in place to eliminate the vulnerabilities with these particular provider and supplier types in these particular geographic areas. (FAQ10416)
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Yes. Within 15 days of receiving the CMS list of providers required to revalidate, Medicare Contractors will mail a noti... (more)

Yes. Within 15 days of receiving the CMS list of providers required to revalidate, Medicare Contractors will mail a notification letter to the large organizations giving them notice that providers reassigned to their group will be receiving a request to revalidate in the next 60 days. A spreadsheet will be mailed, in addition to the letter, identifying the provider’s Name, NPI and specialty. The group notification letter will be mailed to the Authorized or Delegated Official of the organization or the enrollment contact at the group’s correspondence address. The group notification letter is for informational purposes only. Providers/groups should not take any action to revalidate based on the notification letter. Providers/groups should wait until they receive the official revalidation letter from the MAC in a colored envelope before taking any action. (FAQ9194)
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No. Groups with less than 200 reassignments will not receive a letter or spreadsheet from their Medicare Contractor but ... (more)

No. Groups with less than 200 reassignments will not receive a letter or spreadsheet from their Medicare Contractor but can utilize Internet-based PECOS located at https://pecos.cms.hhs.gov/pecos/login.do or the CMS list located at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html on the CMS website to determine if the providers within their group have been mailed a revalidation notice. (FAQ9198)
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Hospital based imaging services billed with place of service (POS) codes 21 (Inpatient Hospital), 22 (Outpatient Hospital) and 23 (Emergency Room – Hospital) will be excluded from the Phase 2 denial edits. (FAQ9218)
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The moratoria extension announced on January 29, 2015, will remain in place for six months, after which CMS will assess ... (more)

The moratoria extension announced on January 29, 2015, will remain in place for six months, after which CMS will assess the need for additional moratoria actions. CMS will communicate the extension through the Federal Register. CMS is continuously monitoring the provider and supplier types subject to the temporary enrollment moratoria. CMS will lift the moratorium if circumstances warranting the moratoria have abated or safeguards are in place to address the fraud risk. (FAQ10418)
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To address the migratory nature of fraud schemes, CMS has extended the moratoria beyond the target counties to the count... (more)

To address the migratory nature of fraud schemes, CMS has extended the moratoria beyond the target counties to the counties that directly border the targets. The moratoria also extend to Medicaid and CHIP operations. The extension to these programs will protect taxpayer dollars. (FAQ10420)
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The Pay.gov site is available 24 hours a day, 7 days a week (holidays included) for users to submit payments, with th... (more)

The Pay.gov site is available 24 hours a day, 7 days a week (holidays included) for users to submit payments, with the exception of a maintenance window every Sunday from 2:00 AM to 6:00 AM Eastern Standard Time. ACH payment processing follows the Federal Reserve holiday schedule; payments will not settle on the following holidays: New Year's Day, Birthday of Martin Luther King, Jr., Washington's Birthday, Memorial Day, Independence Day, Labor Day, Columbus Day, Veterans Day, Thanksgiving Day and Christmas Day. ACH payments submitted by 8:55 PM Eastern Time will settle in your account the following business day. Credit card payments will be processed the next business day as determined by the settlement agent.

6028-FC does not require providers to query a database. Pursuant to our recently published rule newly-enrolling and e... (more)

6028-FC does not require providers to query a database. Pursuant to our recently published rule newly-enrolling and existing providers and suppliers have been placed in one of three screening categories - limited, moderate, or high. These categories represent the level of risk for fraud, waste, and abuse to the Medicare program for the particular category of provider/supplier, and determine the degree of screening to be performed by the Medicare Administrative Contractor (MAC) processing the enrollment application. The screening obligation described in 6028-FC applies to the MACs - not to a provider or supplier. Entirely separate from this rule, there are existing statutes and regulations that prohibit payment for items or services furnished by individuals or entities that have been excluded from participation in Federal health care programs. See, e.g., section 1862(e) of the Social Security Act. A full discussion of exclusion authorities is beyond the scope of this FAQ; please consult with the HHS Office of Inspector General for additional information.

At the end of submitting your payment, you will see a confirmation screen indicating your payment was successful. This c... (more)

At the end of submitting your payment, you will see a confirmation screen indicating your payment was successful. This confirmation screen is your receipt and should be printed for your records. You will also receive a copy of this receipt in your email account if you provided an email address along with your credit card or bank account information. Note - CMS strongly recommends that you attach this receipt to the completed CMS-855 paper application submitted to your Medicare contractors. (FAQ3153)
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CMS will deny claims for ordering/referring providers whose applications are currently in a “pending” status. The physic... (more)

CMS will deny claims for ordering/referring providers whose applications are currently in a “pending” status. The physician or non-physician practitioner must be enrolled in Medicare in an approved or an opt-out status. To verify your ordering and referring status in Medicare, you may access the Ordering Referring Report on the CMS.gov website. The report contains the NPIs and the names of physicians and non-physician practitioners who have current enrollment records in Medicare in an approved or opt out status and are of a type/specialty that is eligible to order and refer. This report is updated on a weekly basis. (FAQ8229)
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In most instances each enrolled provider will receive a separate request to revalidate. Each enrolled institutional prov... (more)

In most instances each enrolled provider will receive a separate request to revalidate. Each enrolled institutional provider and supplier must submit a separate complete revalidation application. Each institutional provider or supplier--such as a pharmacy-- is required to pay an application fee. (FAQ9680)
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The enforcement date of the Part D enrollment requirement has been delayed until December 1, 2015. Therefore, if y... (more)

The enforcement date of the Part D enrollment requirement has been delayed until December 1, 2015. Therefore, if you write prescriptions for covered Part D drugs and you are not enrolled in Medicare or have a valid record of opting- out, you need to submit an enrollment application or an opt- out affidavit to your Medicare Administrative Contractor (MAC) in order for any Part D drugs you prescribe to be eligible for coverage. Prescriber should submit their application to enroll or opt- out affidavit by June 1, 2015 at the latest, to avoid any delays in getting the application/ opt-out affidavit processed by the December 1, 2015 enforcement date. (FAQ11474)
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If the beneficiary gave written permission for the supplier to contact him/her, or if the supplier has already provid... (more)

If the beneficiary gave written permission for the supplier to contact him/her, or if the supplier has already provided a covered item to the beneficiary and the supplier is calling the beneficiary about such covered item, or if the beneficiary has already received a covered item from the supplier in the last 15 months.

As Medicare only pays claims electronically, cancelling EFT enrollment is a choice not applicable to most situations and... (more)

As Medicare only pays claims electronically, cancelling EFT enrollment is a choice not applicable to most situations and will rarely be used. Cancelling EFT enrollment would only be applicable to specific situations, such as a provider opting out of the Medicare program. (FAQ9518)
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The ordering/referring provisions of the final rule only apply to items of DMEPOS, imaging and clinical laboratory servi... (more)

The ordering/referring provisions of the final rule only apply to items of DMEPOS, imaging and clinical laboratory services, and home health services. This final rule does not apply to prescription drugs, or services of physician specialists. (FAQ8191)
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Yes. CMS has determined that the risk posed to Medicare also exists for Medicaid and CHIP. CMS also consulted with... (more)

Yes. CMS has determined that the risk posed to Medicare also exists for Medicaid and CHIP. CMS also consulted with the relevant State Medicaid agencies, which agreed to the terms of the temporary moratoria and that it would not impact access to health care services in the designated geographic areas.

The letter sent from the MAC will include contact information for the CMS Fingerprint Based Background Check Contractor (FBBC).Once the FBBC is contacted, the FBBC will provide locations to be fingerprinted.

Yes, Section 1104 of the Affordable Care Act (ACA) further expands Section 1862 (a) of the Social Security Act mandating federal payments to providers and suppliers only by electronic means. (FAQ3711)
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If a physician contacts a supplier on behalf of a beneficiary with the beneficiary's knowledge, and then a supplier cont... (more)

If a physician contacts a supplier on behalf of a beneficiary with the beneficiary's knowledge, and then a supplier contacts the beneficiary to confirm or gather information needed to provide that particular covered item (including delivery and billing information or information to assure requirements from applicable CMS manuals and LCDs are met), then that contact would not be considered "unsolicited". Please note that the beneficiary need only be aware that a supplier will be contacting him/her regarding the prescribed covered item, recognizing that the appropriate supplier may not have been identified at the time of consultation. (FAQ7545)
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ACH stands for "Automated Clearing House" and refers to an electronic debit from a checking or savings account, commonly... (more)

ACH stands for "Automated Clearing House" and refers to an electronic debit from a checking or savings account, commonly known as a direct debit. This is the option you use to submit checks electronically by entering in your routing, account, and check number. (FAQ3145)
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Yes. Pay.gov uses 128-bit SSL encryption to protect your transaction information while you're logged in to Pay.gov. In addition, any account numbers you set up in your profile are encrypted before being stored in our database. When you access your profile, any account numbers you have entered will be masked on-screen; each account number in your profile will be displayed as a group of asterisks followed by the last four digits of the account number. (FAQ3143)
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Pay.gov transactions will usually appear with the description "CMS Medicare applic fee." If you're not sure what a parti... (more)

Pay.gov transactions will usually appear with the description "CMS Medicare applic fee." If you're not sure what a particular payment is, the first point of contact should be your financial institution. They can help identify the payment history. (FAQ3155)
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